Leading and CGSW Learning in WASH Center for Global Safe WASH The Sustainability of Water Treatment Systems in Healthcare Facilities in Ghana and the Water Infrastructure and Water Quality Which Contribute to Sustainability Compiled by: Mia Gallegos, MDP, Public Health Program Associate, Emory University December 2015 Hospitals in Ghana are…. … Busy …Crowded … Chaotic … unclean floors and surfaces … poor infrastructure Project Overview • General Electric Foundation (GEF) donated decentralized water filtration systems (DWFS) to 5 hospitals with Homespring filters and chlorination systems, 1 hospital with a sand filter system. Bole • District Level Government Hospitals: • 90-100 hospital beds Kintampo • 100-200 patients in clinic per day Kete-Krachi • Rural areas Mampong Apam Axim Typical Filtration System and Piped Water System Map Ghana Untreated Treated 2 Hospital Hospital Ward Chlorine doser Ward 4 Source Hospital 1 Ward 3 6 5 Source GE Homespring Polytank filters (4) Project Objective 1) To evaluate water access, the use of safe water infrastructure for hygiene practices, and the quality of water in healthcare facilities in developing countries. 2) To determine sustainability of ultrafiltration water treatment systems for healthcare facilities. ? ? ? ! ? Methods Mixed Methods Approach: • 6 Health Care Facilities in Ghana • Survey data: interviews addressing knowledge, attitudes, and practices related to water provision and use in the hospital. (N=~300) Emory MPH student, Ledor Igboh, thanks a nurse after an interview (Ghana). – In-depth interviews with administration, directors, maintenance, and lab personnel – Surveys with care providers, staff, patients, and visitors – Facility inspections and Observations regarding water/sanitation infrastructure • Lab data: Tested water samples for microbial and chemical indicators of water quality. (N=~750) – Total Coliforms, E. coli, Pseudomonas Emory MPH student, Samantha Lie- Tjauw, evaluates the hospital water aeruginosa, Chlorine Residual, and Turbidity infrastructure (Honduras). Methods Domain Sustainability Technical On-Site Metric Structure Feasibility Capacity Subdomain •Water Source and •Organization and Sub-domain Availability Communication •Local Access to •Training and Capacity Replacement Parts Strengthening •Current Infrastructure •Maintenance Sub-domain Interview •Water Quality Testing •Repairs Questions Domain Accountability Institutional Sub-domain Water Quality •Monitoring Performance Engagement Data •Oversight by Another Entity •Demand and Awareness •Satisfaction and Perceived Sub-domain •Financial Ownership Value •Finances Observations •Engagement of Hospital Director and Staff •Educational Messaging 0 1 2 3 4 Not sustainable Sustainability Sustainable Cut-Point Water Access Improved Source In Ghana, hospitals on Water average experienced doesn’t flow water shortages once a week. Shortages occur due to seasonal changes and frequent power outages. Duration of the outage Shortages varies. While hospitals in Ghana have access to an improved water source... hospitals do not have consistent water flowing from the taps 100% of the time. Access to Safe Water Infrastructure and Hygiene In addition to Taps are often … Non Existent Non Shortage issues Functional Locked There are Access issues Results – Water Access and use – Handwashing and Sanitation WATER ACCESS AND USE (N=111) 100% 83% 79% 80% 60% 40% 20% 0% FUNCTIONING TAPS FUNCTIONING TAPS WITH SOAP STAFF VS. PATIENT FUNCTIONING TAPS STAFF VS. PATIENT FUNCTIONAL TAPS (N=111) WITH SOAP (N=111) 100% 100% 83% 86% 80% 80% 60% 60% 50% 40% 40% 29% 20% 20% 0% 0% STAFF PATIENT STAFF PATIENT Staff had better access to hand washing facilities and soap than patients. Patient hand washing facilities are needed in order to increase patient hygiene practices and decrease the potential for hospital-acquired infections. Water Quality Data Water Quality Results -Has the water quality changed over time? • The CGSW tested water samples for Total Coliforms, E. coli, Pseudomonas aeruginosa, turbidity, and free as well as total chlorine. • Positive change in water quality overtime • Percentage of samples that meet standards are improving. • Chlorine levels are not within WHO recommended range. In Ghana adherence to chlorine application protocols varied by hospital but overall levels were found to be low due to issues of chlorine supply. Percentage of POU samples from Ghana that met standards between 2013-2015 (N=262) 100% 90% 80% 70% 60% 50% 40% Percent (%) 30% 20% 10% 0% Pseudomonas Total Coliforms E. coli Free Chlorine aeruginosa 2013 49% 60% 45% 29% 2014 44% 70% 35% 19% 2015 58% 77% 69% 11% *WHO Guideline: <1 MPN/100 mL **CDC Safe Water System Guidelines for free chlorine residual: 0.20-2.00 ppm † Currently standards do not exist for pseudomonas aerugionsa because infectious dose has not been determined. According to expert opinion concentrations >10,000 MPN per 100 mL found in water could be of public health concern. This table notes the presence of pseudomonas aerugionsa in samples. *** POU: Point of Use, Filtered water that comes from the tap within the department. POU samples in Ghana include samples collected from the tap as well as Veronica Buckets. Water Quality Results • Water quality results varied by hospital. • Only one hospital was able to achieve consistent access to water, which met WHO guidelines. Hospital A (N=17) Hospital B (N=N/A) District Hospital C (N=16) Hospitals in Hospital D Ghana Hospital E (N=8) Hospital F (N=10) District (N=7) Hospitals in (N=8) Honduras (N=15) * POU samples in Ghana include samples collected from the tap as well as Veronica Buckets. % of samples that meet WHO Guidelines Typical Filtration System and Piped Water System Map Ghana Untreated Treated Hospital Hospital Hospital Hospital Ward Ward Ward Ward Chlorine doser 4 Source 1 3 Hospital 2 Ward Source GE Homespring Polytank filters (4) • What makes delivering quality water difficult? • There are multiple buildings. • Built at different times by different groups. • No records of maps of the plumbing. • Water quality can decrease within the piped network in the following ways: 1. Water can flow directly from the filtration system into the wards. 2. There can be multiple sources of water, some passing through the filtration system some not. 3. Water can be stored in a polytank then go to the hospital ward. 4. Water can cascade from 1 polytank to another then go into hospital wards. Water Storage Containers Typical Filtration System and Piped Water System Map Ghana Untreated Treated Hospital Hospital Hospital Hospital Ward 5 Ward Ward Ward Chlorine doser 4 Hospital Source Ward 6 1 3 Hospital 2 Ward Source GE Homespring Polytank 7 filters (4) • What makes delivering quality water difficult? • There are multiple buildings. • Built at different times by different groups. • No records of maps of the plumbing. • Water quality can decrease within the piped network in the following ways: 1. Water can flow directly from the filtration system into the wards. 2. There can be multiple sources of water, some passing through the filtration system some not. 3. Water can be stored in a polytank then go to the hospital ward. 4. Water can cascade from 1 polytank to another then go into hospital wards. 5. Water can flow directly from one ward to another. 6. Hospital wards can be piped differently. (ex: half of the ward can be piped to receive filtered water, the other can be getting treated water). 7. Water can be stored in various containers (ex: Veronica Buckets, bowls, jerry cans, and drums). Water Storage Containers Water Storage Containers WHO Guidelines for Chlorine Residual: 0.20-2.0 ppm If water remains in storage containers for more than 24 hours chlorine residual will not be present. (As seen in this picture). Additionally if storage containers are not cleaned regularly, chlorine residual levels will be lower than in storage containers that are cleaned regularly. Possible ways contamination is reintroduced due to water collection practices. Water Quality Comparisons: Total Coliforms in Raw and Treated Water - 2014 Raw water was more contaminated than the filtered water and the tap water. However there was a rise in total coliforms in the water storage containers. Dirt and biofilm inside a piece of pipe cut from hospital network. Water Quality Comparisons: E. coli in Raw and Treated Water - 2014 Raw water was more contaminated with E. coli than the filtered water. Recontamination with fecal bacteria was occasional. Water Quality Comparisons: Pseudomonas aeruginosa in Raw and Treated Water - 2014 Pseudomonas aeruginosa was present in raw or filtered water but not in large amounts. Noticeable concentrations in tap water and Veronica Bucket water were found. Water Quality Comparisons: Paired Profiles for Tap and Veronica Bucket Samples - Water - 2014 Most paired samples follow the same general trend and the change was significantly different. (P value of 0.03). Water stored in veronica buckets within hospital wards are highly contaminated with Pseudomonas aeruginosa. For this reason, it is recommended that the use of veronica buckets should be minimized and ultimately discontinued. Pseudomonas Pseudomonas aeruginosa in aeruginosa in Tap Water Veronica Bucket Water Water Storage Containers • The CGSW found contamination in Veronica buckets at 6 hospital sites in Ghana. • Buckets were used at all 6 hospital sites and were rarely cleaned. • After Veronica bucket cleaning protocol and management system was implemented: • The presence of total coliforms, E.